Club Sports Accident Report Form

Please fill out as accurately as possible, and submit as soon after accident as possible.

IDENTIFICATION INFORMATION
Name (person involved in incident/accident) * First Last
ID Number *
Checkboxes * Male Female
Date of Incident * / MM / DD YYYY
Sport in which accident occurred *
Location of incident/accident *
Time of incident/accident * : HH MM AM/PM
Name of person filling out report * First Last
Incident/accident report filing date * / MM / DD YYYY
ACCIDENT DESCRIPTION
Describe injury (using left, right, etc.) *
Description of incident/accident *

Fully describe events, actions and conditions involved.
Was immediate first aid administered? (Yes/No) If Yes, describe. *
Was person referred to Health Services? * Yes No
Was Safety & Security notified for emergency transport? * Yes No
Was person taken to hospital? * Yes No
If yes, name of hospital.
Other actions taken at time of injury: